PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES INDIVIDUAL TREATMENT PLAN

Transcription

1 INDIVIDUAL TREATMENT PLAN PATIENT NAME: John Doe PATIENT ID # 9078 ADMISSION AXIS AXIS I: 303.9, II: Deferred I: III: Nicotine use I: IV: Legal Issues; family issues Axis I co-occurring mental health disorder(if applicable) I: V: 55 Axis I co-occurring mental health disorder(if applicable) NAME and SIGNATURE OF RESPONSIBLE CLINICAL STAFF MEMBER: Dana Flanigan, BA, Addictions Counselor By signing, I attest that I have participated with the treatment staff in the development of this treatment plan: SIGNATURE OF PATIENT: SIGNATURE OF PARENT (When Applicable): SIGNATURE OF CASAC: MULTI-DISCIPLINARY TEAM APPROVAL SIGNATURE OF QHP OTHER THAN CASAC: SIGNATURE OF MEDICAL STAFF MEMBER: NOTE: The individual treatment plan must be established within 30 days of admission. The individual treatment plan is established upon review and approval by the Multi-Disciplinary Team. SIGNATURE OF MEDICAL DIRECTOR/STAFF PHYSICIAN: NOTE: If the physician has signed the individual treatment plan as part of the Multi-disciplinary Team, a second physician signature is not required. Also, if the Physician s signature is added separately and not as part of the Multidisciplinary Team it must be signed within 7 days of the Multi-disciplinary Team approval.

2 Patient Name: John Doe Identified Functional Area Chemical Use, Abuse and Dependence: Client has been diagnosed as alcohol dependent, cannabis abuse, and nicotine dependent as evidenced by: tolerance, failed efforts to stop and cut down use, continued use despite legal consequences, and continued use despite psychological consequences. John will develop an understanding that she is suffering from the disease of addiction and learn the skills necessary to maintain a sober lifestyle and a lifelong recovery program. Client will share in individual sessions her understanding of his addiction and ask for feedback Client will remain abstinent during the course of treatment. Client will share in group his understanding of his addiction and ask for feedback. 11/2/11 11/2/11 11/2/11 Client will attend individual sessions 2x/ month for 60 minutes with Dana and be monitored for participation and progress through individual notes Client will submit to random drug and urine screenings at a minimum of once a month when requested by his primary counselor. Client will attend group therapy 1x/week for 90 minutes, and be monitored for participation and progress through group notes. Client will begin to develop a sober support network. Client will develop a Relapse Prevention Plan before he completes treatment. Client will develop a discharge plan conducive to continued recovery. 9/1/11 10/15/11 11/1/11 Client will attend one self help meetings of his choosing and report back to her primary what, if any, support he found there. Client will complete Relapse Prevention workbook with writer, complete all assignments and develop a relapse prevention plan Client will work with his primary on a discharge plan that includes all life areas and keep a copy for his own reference. 2

3 Patient Name: John Doe PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES Identified Functional Area Social / Leisure / Activities of Daily Living: Client, by his own admission, tends to isolate from society in general. Client reports no real issues with leisure time activities. No issues with activities of daily living Client will develop healthy socialization skills that do not rely on the use of mood altering substances. Client will make a list of people he feels comfortable in being with. 8/1/11 Client will review his list with his primary in an individual session. Client will make a list of five group leisure activities that are of interest to him 8/1/11 Client will review his list with his primary in individual session. Client will attend one social activity with someone he is comfortable with. 8/1/11 Client will ask a group member to go have coffee with him sometime after group. 3

4 Patient Name: John Doe PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES Identified Functional Area Vocational / Educational / Employment: Client Is currently on disability due to mental health reasons, and is not looking for work. Client will complete the vocational assessment in order to complete this goal Client will meet with the agency Vocational Specialist to assess his needs and interest. 7/1/11 Client will make an appointment, through his primary, to meet with the Vocational Specialist. 4

5 Patient Name: John Doe PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES Identified Functional Area Family / Significant Other: Client has alienated himself from his family due to his addiction and their disapproval. Client will learn healthy communication skills to foster a reunification with his family. Client will review materials regarding the effects of addiction on the family system. Client will identify changes he must make to foster his relationship with his family. 9/1/11 10/1/11 Client will complete a workbook on addiction in the family and discuss his findings with his primary counselor. Client will facilitate action plans with writer to process changes 5

6 Patient Name: John Doe Identified Functional Area Legal: Client is currently on probation due to fighting. Criminal mischief in the 4 th degree and criminal trespass in the 3 rd. He will be on probation for two more years. Client will continue to follow any recommendations by probation in order to resolve his legal issues Client will follow all conditions of probation in order to resolve his legal issues. 11/2/11 Client will report his compliance to his primary counselor. Client will discuss the correlation between his use and legal issues 9/15/11 Client and writer will discuss the correlation, and his thoughts and feelings behind the correlation 6

7 Patient Name: John Doe Identified Functional Area Medical / Physical Health: (Include any identified needs based on the results of the communicable disease risk assessment): Client has an addiction that can greatly impact his physical well-being and health and has had a physical in the past year. Client will keep writer informed of any changes that may occur. Client smokes 1/2 pack of cigarettes per day. Client will follow up with his doctor any medical concerns that he may have Client will address his addiction to nicotine. 11/1/11 9/15/11 Client will tell his primary who he plans to see, when and where, he plans to see them. Client and writer will discuss options for NRTs, as well as the benefits of quitting smoking. 7

8 Patient Name: John Doe Identified Functional Area Mental Health and/or Emotional Health: Client self reports that he is in mental health treatment at ARA. Client reports that he is diagnosed with bipolar, and is on disability due to his mental health diagnoses. Client will continue to engage in mental health treatment in order to be able to seek treatment for his addiction. Client will continue to engage in mental health treatment at ARA 11/111 Client will tell writer any changes that may occur, as well as any issues that may arise. 8

9 Patient Name: John Doe PART 822 CHEMICAL DEPENDENCE OUTPATIENT SERVICES Description and Nature of Additional Service/Referral: Client is currently on probation due to his legal issues /Time of Referral Since before treatment Results of Referral: Client will sign a consent for his probation officer Procedures for Ongoing Coordination of Care: Client will keep both his primary at ACASA and probation informed of his compliance or lack of compliance with each agency. Description and Nature of Additional Service/Referral: /Time of Referral Results of Referral: Procedures for Ongoing Coordination of Care: 9